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b <br /> San Joaquin County Environm ?ntal Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> 248 EAST PARK ST, STOCKTON <br /> I JOB ADDRESS: 11536 NORTH HUNTER STREET <br /> PERMIT SR # <br /> LICENSED CONTRACTOR` DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions o Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the California Business and Professions Cod� and my license Is in full force and effect. <br /> License#: Exp Date: ( ,� L <br /> Date: /-A I k l G r v) Contractor: <br /> Signature ) Title: ��( <,,r If-1 1 <br /> Print Name: , ''I I <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the followinc declarations (check one) <br /> I have and will maintain a certificate of consent to self-insure for workers' compensation, as <br /> provided for by Section 3700 of the Labor Code. for the performance of the work for which this <br /> permit is issued <br /> _X I have and will maintain workers' compensation i isurance, as required by Section 3700 of the <br /> Labor Code, for the performance of the work for which this permit is issued My workers' <br /> compensation insurance carrier and policy number. are: <br /> Carrier: lA ICA P:)Iicy Number: <br /> I certify that in the performance of the work for whi :h this permit is issued. I shall not employ any <br /> person in any manner so as to become subject tc the workers' compensation law of California, <br /> and agree that if I should become subject to workers' compensation provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date: I2A I I ) nz Signature: <br /> Print Name:_� <br /> WARNING FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO $100.000. IN A)DITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECT ON 3706 OF THE LABOR CODE <br /> AUTHORIZATION FOR OTHER THAN C-57 IGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), <br /> hereby authorize (print name) to sign ti is San Joaquin County Well & Boring Permit <br /> Application on my behalf. I understand this authorization is valid for one year and is limited to the work <br /> plan dated on the front page of this application. <br /> EMD 29-01 0v13111 <br /> ✓YELL PFRYiT AP <br />